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2. First Name*
3. Last Name*
5. House Number*

   Please add ONLY your house number here

6. Street Name*

   Please add your street name without the house number here

8. City
9. State
10. Zip Code
12. Email Address
13. Phone Number*
15. Please Indicate the Date(s) You Would Like Collections*

    1. April 22nd

    This form is for April 22nd collection only.

17. Number of Bags (LEAVES & YARD WASTE) to Be Collected*

    Please estimate, to the best of your knowledge, the number of biodegradable (no plastic) bags containing LEAVES AND YARD WASTE ONLY you will be putting out for collection.

18. Number of Bags (TWIGS ONLY) to Be Collected*

    Please estimate, to the best of your knowledge, the number of biodegradable (no plastic) bags containing TWIGS ONLY you will be putting out for collection.

19. Number of Tied Bundles of Sticks*

    Please estimate, to the best of your knowledge, the number of tied bundles of STICKS ONLY you will be putting out for collection. Please use biodegradable twine to tie the bundles.

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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field